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MODERATEPRAM: 4-7

MILDPRAM: 1-3

INITIAL EMERGENCY MANAGEMENT OF ACUTE ASTHMA IN CHILDREN BASED ON PRAM ASSESSMENT

ObTAIn PEDIATRIc REsPIRATORy AssEssMEnT MEAsuRE (PRAM)

Sign 0 1 2 3

Suprasternal Indrawing

Absent Present

Scalene Contraction Absent Present

Air-entry Normal Decreased at bases

Widespread decrease Absent/minimal

Wheezing Absent Expiratory only

Inspiratory & expiratory

Audible wheezing/silent chest

SaO2 on R/A ≥95% 92 – 94% <92%

• Children 1-14 yrs of age presenting to ER with shortness of breath and wheezing, and either of the following: 1. Prior diagnosis of asthma by an MD, 2. Past-history of wheezing attack responsive to bronchodilator.• Exclude infants presenting with first wheezing episode or children presenting with features of upper airway obstruction (e.g. stridor) as the cause for their shortness of breath.

ER PRAM PATHWAY INCLUSION CRITERIA:

Source: Annals of Thoracic Medicine 2019; Volume:14, Issue:1

www.saudithoracic.com

• Salbutamol: <20 Kg: via MDI/spacer 5 puffs, via nebulizer 2.5 mg, >20 Kg: via MDI/spacer 10 puffs, via nebulizer 5 mg (titrate MDI/spacer dose based on response)• Ipratropium: via MDI/spacer 4 puffs, via nebulizer 250 mcg• IV Salbutamol: 1 mcg/Kg/min then titrate PRN (max dose 10 mcg/Kg/min)

• MgSO4: 40 mg/Kg IV bolus over 20 min (max dose 2000 mg)• Systemic steroids: - Hydrocortisone 8 mg/Kg (max dose 400 mg) - Dexamethasone 0.3 mg/Kg (max dose 10 mg) - Methylprednisolone/prednisolone 2 mg/Kg (max dose 60 mg)

MEDICATION DOSAGE

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A Quick Guide For AsthmA mAnAGement in

Children

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Easy asthmaFlowcharts®

Children

(Discharge Plan)

• Salbutamol PRN• Complete the course of prescribed oral steroids• Inhaled steroid, if indicated • Provide action plan/ asthma education• Clinic visit within one week

• PRAM: 4-7 Follow instruction under “Moderate” pathway

• PRAM: 8-12 Follow instruction under “Severe” pathway

• IV access and fluids• Continuous Salbutamol Nebulizer• Consider IV Salbutamol• ABG and consider CXR• Monitor electrolytes• Contact PICU for Admission

(Discharge Plan)

• Observe for 1 hour after last bronchodilator• If PRAM ≤3 discharge home• Salbutamol Q 4-6 hours X 24 hours then PRN • Inhaled steroids till next clinic visit• Complete oral steriods course• Provide action plan/ asthma education• Clinic visit within one week

• Continue salbutamol Q 30 min for 3 doses, Re- ssess PRAM

If PRAM 4-7 - IV magnesium sulphate - Admission is recommended

PRAM8-12

PRAM 1-3

PRAM1-3

PRAM4-7

1. Vital signs initially & at discharge2. Keep SaO2 >92% (use O2 if needed)3. Salbutamol and Ipratropium bromide Q 20 min for 3 times4. Systemic steroid after first Bronchodilator5. Re-assess PRAM after 1 hour

PRAM1-3

PRAM> 3

1. Vital signs initially & at discharge2. Keep SaO2 >92% (use O2 if needed)3. Initial Salbutamol, re-assess, if no response:

- Continue Salbutamol Q 20 min for two doses - Consider Ipratropium bromide and oral steroids

4. Re-assess PRAM after one hour.

sEVEREPRAM: 8-12

(Discharge Plan)

• Observe for 1 hour after last Bronchodilator• If PRAM ≤3 discharge home• Salbutamol Q 4-6 hours for 24 hours then PRN• Inhaled steroids till next clinic visit• Oral steroid to complete the course• Provide action plan/ asthma education• Clinic visit within one week

Consult PICU for Admission

• Continue Salbutamol Q 30 min for 3 doses, Re- Assess PRAM

If PRAM 4-7 - IV magnesium sulphate - Admission is recommended

P RAM 1-3

PRAM 8-12

1. Vital signs Q 20 min until improvement2. O2 Supplementation to keep SaO2 ≥94%3. Salbutamol + Ipratropium bromide Q 20 min for 3 times

4. Systemic steroid after first Bronchodilator5. Consider IV access and fluids6. Re-assess PRAM after 1 hour

PRAM1-3

PRAM4-7

PRAM8-12

PRAM <8

PRAM8-12

• IV access and fluids• Continuous Salbutamol Nebulizer• Consider IV Salbutamol• ABG and consider CXR• Monitor electrolytes• Re-assess PRAM after 1 hour

ABG: Arterial Blood Gas, CXR: Chest X-Ray, IV: Intravenous, O2: Oxygen, PICU: Pediatric Intensive Care Unit,

PRAM: Pediatric Respiratory Assessment Measure, SaO2: Oxygen Saturation, R/A: Room Air

AbbREvIATION:

The Saudi Initiative for

Asthma2 0 1 9

TABLE 1: THE TEST FOR RESPIRATORY AND ASTHMA CONTROL IN KIDS (TRACK) FOR CHILDREN < 5 YEARS OF AGE SCORE

TOTAL SCORE

OUTPATIENT MANAGEMENT OF ASTHMA IN CHILDREN (< 5 YEARS) SUPPLEMENTSOUTPATIENT MANAGEMENT OF ASTHMA IN CHILDREN (> 5 YEARS)

Copyright © 2019 STS-SINA. All Rights Reserved Copyright © 2019 STS-SINA. All Rights Reserved Source: Annals of Thoracic Medicine 2019; Volume:14, Issue:1

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ChildrenChildren

Use Step-Up approach if uncontrolled or Step-Down approach if controlled for 6-12 weeks

sTEP 2

Low dose ICSAlternative:

Leukotriene modifier

sTEP 3

Preferred:double

dose ICSAlternative:

Low dose ICS+

Leukotrienemodifier

sTEP 4

Double dose ICS +

Leukotriene modifier

sTEP 5

Step 4 Regimen

+Systemic steroid

Salbutamol (as needed)

sTEP 1

Salbutamol(As needed) Refer to Specialist

Daytime symptoms None (twice or less/week) >2 days/week >2 days/week

Limitations of activities None Any Any

Nocturnal symptoms None Any Any

Bronchodilator use ≤2 days/week >2 days/week >2 days/week

Characteristics Controlled (all of the following) Partially controlled (any of the following) Uncontrolled (≥3 of the following)

ABG: Arterial Blood Gas, CXR: Chest X-Ray, IV: Intravenous, O2: Oxygen, PICU: Pediatric Intensive Care Unit, PRAM: Pediatric Respiratory Assessment Measure, SaO2: Oxygen Saturation, R/A: Room Air

AbbREvIATION:

•Risk assesment•Challenge diagnosis (is it asthma?)• Environmental control

• Asthma education• Evaluate compliance

Additionally, you may use TRACK Score to further assess asthma control

PHYSICIAN ASSESSMENT OF ASTHMA CONTROL

Use Step-Up approach if uncontrolled or Step-Down approach if controlled for 6-12 weeks

sTEP 2

Low dose ICSAlternative:Leukotriene

modifier

sTEP 3

Low dose ICS + LABAAlternative:

Medium - high dose ICS,

OrLow dose ICS

+Leukotriene

modifier

sTEP 4

Medium - high dose ICS + LABA

+/-Leukotriene

modifier

Salbutamol (As needed)

sTEP 1

Salbutamol(As needed) Refer to Specialist

sTEP 5

Step 4 regimen

+Systemic Steroid

Consider:Biologic Therapy

•Risk assesment•Challenge diagnosis (is it asthma?)• Environmental control

• Asthma education• Evaluate compliance

ABG: Arterial Blood Gas, CXR: Chest X-Ray, IV: Intravenous, O2: Oxygen, PICU: Pediatric Intensive Care Unit, PRAM: Pediatric Respiratory Assessment Measure, SaO2: Oxygen Saturation, R/A: Room Air

AbbREvIATION:

Additionally, you may use C-ACT Score to further assess asthma control

Daytime symptoms None (twice or less/week) >2 days/week >2 days/week

Limitations of activities None Any Any

Nocturnal symptoms None Any Any

Bronchodilator use ≤2 days/week >2 days/week >2 days/week

PHYSICIAN ASSESSMENT OF ASTHMA CONTROLCharacteristics Controlled (all of the following) Partially controlled (any of the following) Uncontrolled (≥3 of the following)

1. During the past 4 weeks, how often was your child bothered by breathing problems (wheezing, coughing, SOB)?

Not at all (20) Once or twice (15) Once every week (10) 2-3 times/week (5) ≥4 times/week (0)

2. During the past 4 weeks, how often did your child’s breathing problems, such as wheezing, coughing, or SOB, wake him/her at night?

Not at all (20) Once or twice (15) Once every week (10) 2-3 times/week (5) ≥4 times/week (0)

3. During the past 4 weeks, to what extent did your child’s breathing problems, such as wheezing, coughing, or SOB, interfere with his/her ability to play, go to school, or engage in usual activities that a child should be doing at his/her age?

Not at all (20) Once or twice (15) Once every week (10) 2-3 times/week (5) ≥4 times/week (0)

4. During the past 3 months, how often did you need to treat your child’s breathing problems (wheezing, coughing, or SOB) with quick-relief medications?

Not at all (20) Once or twice (15) Once every week (10) 2-3 times/week (5) ≥4 times/week (0)

5. In the past 12 months, how often did your child need to take oral corticosteroids for breathing problems not controlled by other medications?

Not at all (20) Once or twice (15) Once every week (10) 2-3 times/week (5) ≥4 times/week (0)

TRACK Score < 80 Indicates Uncontrolled Asthma

TABLE 2: THE CHILDHOOD ASTHMA CONTROL TEST (C-ACT) FOR KIDS 4-12 YEARS OF AGE SCORE

CHIL

DCA

REGI

VER

TOTAL SCORE

1. How is your asthma today?

Very bad (0) Bad (1) Good (2) Very good (3)

2. How much of a problem is your asthma when you run, exercise, or play sports?

It’s a big problem; I can’t do what I want to do! (0) It’s a problem & I don’t like it (1) It’s a little problem and but it’s okay (2) It’s not a problem (3)

3. Do you cough because of your asthma?

Yes, all of the time (0) Yes, most of the time (1) Yes, some of the time (2) No, none of the time (3)

4. Do you wake up during the night because of your asthma?

Yes, all of the time (0) Yes, most of the time (1) Yes, some of the time (2) No, none of the time (3)

5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?

Not at all (5) 1-3 days (4) 4-10 days (3) 11-18 days (2)

6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?

Not at all (5) 1-3 days (4) 4-10 days (3) 11-18 days (2)

7. During the last 4 weeks, how many days did your child wake up during the nigh because of asthma?

Not at all (5) 1-3 days (4) 4-10 days (3) 11-18 days (2)

C-ACT Score < 19 Indicates Uncontrolled Asthma

C-ACT: Childhood Asthma Control Test, ICS: Inhaled Corticosteroids, Ig E: immunoglobulin E, LABA: Long Acting β2Agonist, PRN: As Needed, TRACK: Test for Respiratory and Asthma Control in Kids

AbbREvIATION:

AGE PREFERRED DEvICE ALTERNATE DEvICE

<4 years Pressurized MDI + dedicated spacer with face mask Nebulizer with face mask

4-6 years Pressurized MDI + dedicated spacer with mouthpiece Nebulizer with mouthpiece

>6 years Dry-powder inhaler, or, Breath-actuated pressurized MDI, Nebulizer with mouthpiece or Pressurized MDI + dedicated spacer with mouthpiece

Table 3: Selection of inhaler device in children